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Papillary Muscle Cross-Control Technique to Overcome Excessive Leaflet Tethering in Complex Tricuspid Valve Repair

Tuesday, October 26, 2021

Amirghofran AA, Nirooei E. Papillary Muscle Cross-Control Technique to Overcome Excessive Leaflet Tethering in Complex Tricuspid Valve Repair.. October 2021. doi:10.25373/ctsnet.16873456

Longstanding tricuspid valve regurgitation (TR), either of functional or organic origin, might lead to severe right ventricular (RV) dilatation and/or dysfunction. The chordal shortening caused by papillary muscle displacement secondary to marked RV dilatation results in severe leaflet tethering and progressive lack of coaptation, which makes the tricuspid valve repair surgery much more complicated. The annular and RV wall dilatation occurs mostly in the anteroposterior commissure parts and the septal area is less involved. The tricuspid valve tethering distance, which is measured as the distance between the annular plane and the coaptation point, has been proven as the primary independent parameter predicting residual TR (1).

Although annular remodeling and downsizing by annulopasty ring restore coaptation in most cases, residual central regurgitation due to excessive leaflet tethering in advanced cases needs to be managed in order to have a better and more durable result. In fact, in the presence of severely tethered leaflets, the TR recurrence rate is 15 to 30 percent, and it has long been recognized that ring annuloplasty is unlikely to successfully treat severe leaflet tethering in TR (2). Some suggested techniques, including bicuspidisation, the clover edge-to-edge technique, and patch augmentation, may be mostly either non-physiologic with some tethering remaining, or complex and time consuming (3).

We describe a novel technique that simultaneously overcomes the excessive leaflet tethering, restores coapation, and controls right ventricular free wall distension. In this simple and reproducible technique, the mostly displaced papillary muscle that is usually in the anteroposterior area is controlled by a re-enforced suture that then crosses the ventricular cavity to pass behind the septal leaflet through the septal part of the annuloplasty ring. Controlled pulling of this suture during the water test, pulls down the anterior papillary muscle posteriorly and approximates the leaflets together. The suture is then tied in the most suitable length over the annuloplasty ring. A concomitant advantage of this technique is prevention of overdistension of the right ventricle by approximating the mid-anterior free wall to the posterior annulus by a fixed length and subsequent decrease of the wall tension referred to in LaPlace's law. This technique can be used in any patient who shows excessive leaflet tethering and apical displacement of the coaptation point after correction of the organic lesion and semi-rigid ring annuloplasty procedure, including patients with the simpler condition of longstanding functional TR with RV dilatation, as well as patients with much more complex organic tricuspid valve disease such as severe Ebstein's anomaly. In most of our cases, only one cross-control suture to the dominantly tethering papillary muscle has been sufficient, but in some cases more than one papillary muscle needs to be controlled.

Our immediate, short, and mid-term results with up to five year's of follow-up have been encouraging, showing no increase in RV size or recurrence of TR. In conclusion, we have found the papillary muscle cross-control a simple, safe, and very effective technique to eliminate the compromising effect of leaflet tethering in complex tricuspid valve repair.


  1. Fukuda S, Song JM, Gillinov AM, McCarthy PM, Daimon M, Kongsaerepong V, Thomas JD, Shiota T. Tricuspid valve tethering predicts residual tricuspid regurgitation after tricuspid annuloplasty. Circulation. 2005 Mar 1;111(8):975-9.
  2. Dreyfus GD, Raja SG, John Chan KM. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. European journal of cardio-thoracic surgery. 2008 Oct 1;34(4):908-10.
  3. Choi JB, Kim NY, Kim KH, Kim MH, Jo JK. Tricuspid leaflet augmentation to eliminate residual regurgitation in severe functional tricuspid regurgitation. The Annals of thoracic surgery. 2011 Dec 1;92(6):e131-3.


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We have been using this for years and in addition, add a contralateral tethering stitch from the Septal leaflet to reinforce coaptation and have good long-term results with it. Particularly important when there is a tenting height is more than 10 mm
Lohchab SS, Chahal AK, Agrawal N. Papillary muscle approximation to septum for functional tricuspid regurgitation. Asian Cardiovasc Thorac Ann. 2015 Jul;23(6):747-50. doi: 10.1177/0218492315570644. Epub 2015 Jan 29. PMID: 25635105. I have already published the technique which has been little modified here. Our technique has many citations including Sabiston and Spensor Surgery of Chest Text book .
Dear dr. Lohchab. Thank for your comment and your fantastic paper. I appreciate that the main concept in both techniques is to displace the anterior papillary muscle in such a way to overcome the tethering. But they are completely different in terms of type and direction of the displacement and furthermore this is a completely *controlled* adjustment of the displacement under direct visualization of the valve function which is a very imporant point. Thanks again for the concern.
Nice video and presentation! The repair addresses the previously described 'Sphericity of the RV", which has been quantified with a sphericity index. In principle, the anterior papillary muscle moves away from the septum as a consequence of RV dilation. The classical Sebening stich addressed this and involved approximating the anterior papillary muscle to the interventricular septum and was used for Ebstein's anomaly. Since then, there have been a number of modifications such as approximating the anterior papillary muscle to the septal papillary muscle to reduce the amount of tension. Dimpling of the RV-free wall was associated with the dehiscence of this stitch in the early post-op period and hence the recommendation of mobilizing the anterior papillary muscle in addition to avoid this undesired outcome. Your repair is to a more rigid annuloplasty ring and pulls the anterior papillary muscle in an inferior and anterior fashion. Have you noted any dehiscence of stitch in any of your cases?
Dear dr sainathan. Many thanks for your comment and great explanation. We have net been facing with suture dehiscence problem yet. We think that 2 points in the technique may have decreased the chance of dehiscence. First the direction of the the suture and the tension which is just the normal dirction (towards the annulus) in contrast to the papillary musle to septum connection which the direction of tension is more or less verical and not the phsiologic direction. Second, the pulling suture is controlled just as much as needed to bring the coaptation to the level of annulus and not complete connection of the anterior pap muscle to the septum or the septal pap muscle which obviously increases the tension.Thanks again for your concern and coment.
Very elegant technique. Very well reasoned and beautifully executed. The teaching video is also extremely clear. My most sincere congratulations to Doctor Amirghofran. I am looking forward to using this technique at the first opportunity. Very many thanks for your valuable contribution.
This is an awesome technique and reproducible. I did this technique for the 80-year-old severe TR patient due to untreated ASD and had a great result. Thanks, Dr. Amirghofran.

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